Ibrahim Card Med J 2019; 9 (1&2): 54-59

 Ibrahim Cardiac Hospital & Research Institute

Pattern of Drugs Use in Selected Paediatric Diseases in Outpatients

Departments of Public and Private Teaching Hospitals in Bangladesh
Tasnin Afrin,1 Rumana Afroz,2 Shahin Sultana,3 Kamrunnesa,4 Mahbuba Jahan Lotus5

ABSTRACT
Background & objective: Appropriate use of drugs are important in any diseases in any population. It is
particularly so in children. To evaluate whether drugs are properly utilized in terms of efficacy, safety,
convenience and economic aspects at all levels in the chain of drug use, periodic studies addressing the
utilization of drugs in different health care setting are essential. Various drug utilization studies have been
ORIGINAL ARTICLE

carried out all over the world but there are limited studies addressing drug use patterns in pediatric population
in Bangladesh. The present study is one such step to evaluate the pattern of drug use in different pediatric
diseases among patients attending at pediatric out-patient department (OPD) in two selected medical college
hospitals.

Methods: This cross-sectional study was conducted in the paediatric OPD of two tertiary care hospitals, Sir
Salimullah Medical College & Mitford Hospital (SSMC & MH) (a public hospital), Dhaka and Dhaka National
Medical College (DNMC) & Hospital (a private hospital). A total of 600 children (300 from each of the two
Medical College Hospitals) were selected as study subjects. Three hundred prescriptions audited in SSMC & MH
contained a total 946 drugs and 300 prescriptions audited in DNMC contained 990 drugs in total. Patients got
admitted during out-patient department visit were excluded from the study. The age and sex of the patients
and medications use-related variables like dose, frequency, duration and route of administration of the drugs
were noted. Pattern of drug use in the hospitals for pediatric population was evaluated.

Results: The study subjects of the two tertiary hospitals were almost identical in terms of age and sex (p =
0.181 and p = 0.369 respectively). Use of three drugs per encounter was commonly observed in both the
hospitals. Around one-third of the prescriptions contained four drugs. Prescription of five drugs was rare in both
the hospitals. Prescription with two drugs was higher in SSMC & MH than that in DNMC Hospital (p = 0.043).
Majority of the prescriptions from SSMC (83.1%) contained drugs within essential drug list (EDL) compared to
that from DNMC (73%) (p< 0.001). The highest prescribing drug was antibiotic, both in SSMC (22.7%) and
DNMC (23.2%) (p = 0.417) followed by analgesic (18% in SSMC and 17.7% in DNMC), anti-diarrhoeal. The less
commonly used drugs were gastric acid suppressant, antispasmodic, anthelmintic, antiemetic, while rarely
prescribed drugs were antihistamines, antiasthmatic and nasal drops. Pattern of drugs prescribed in two
hospitals were similar (p > 0.05).

Conclusion: The study concluded that the rate of antibiotics prescribed in both public and private hospitals is
higher. Further studies teaching hospitals etc. are required for the monitoring of drug utilization pattern and
formulation of Standard Treatment Guidelines (STG) for the physicians is essential.

Key words: Pattern of drug use, Pediatric diseases, Outpatients department, Public & private teaching
hospitals etc.

Authors’ information:
1
Dr. Tasnin Afrin, Assistant Professor, Department of Pharmacology & Therapeutics, Dhaka Community Medical College. Dhaka.
2
Dr. Rumana Afroz, Assistant Professor, Department of Pharmacology & Therapeutics, Dhaka Medical College. Dhaka.
3
Dr. Shahin Sultana, Assistant Professor, Department of Pharmacology & Therapeutics, Mymensingh Medical College, Mymensingh.
4
Dr. Kamrunnesa, Assistant Professor, Department of Pharmacology & Therapeutics, Shahabuddin Medical College, Dhaka.
5
Dr. Mahbuba Jahan Lotus, Assistant Professor, Department of Pharmacology & Therapeutics, Dhaka Medical College, Dhaka.
6
Prof Dr. Ferdous Ara, Department of Pharmacology, Delta Medical College, Dhaka
Correspondence: Dr. Tasnin Afrin, Cell Phone: +88 01726138327, E-mail: ujala1410@gmail.com

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Pattern of Drugs Use in Selected Paediatric Diseases in Outpatients Departments of Public and Private Teaching Hospitals in Bangladesh Afrin et. al.

INTRODUCTION: prescribing practices and characterizes the early

signals of irrational drug use. With the help of WHO
Pediatrics is the branch of medicine dealing with the
prescribed drug use indicators and concept of defined
development, diseases and disorders of children.1
daily doses it is possible to compare drug utilization
Drug therapy is considered to be the major
patterns between different settings.13 Appropriate
component of pediatric management in health care
drug utilization studies are, therefore, important tools
settings like hospital. The use of antimicrobial agents,
to evaluate whether drugs are properly utilized in
specially antibiotics has become a routine practice for
terms of efficacy, safety, convenience and economic
the treatment of pediatric illness.2 However, there are
aspects at all levels in the chain of drug use.14 Various
also reports of an irrational use of antibiotics,3 which
drug utilization studies have been carried out all over
may even lead to infections worse than originally

ORIGINAL ARTICLE
the world but there are limited studies addressing drug
diagnosed ones. Inappropriate prescribing is a
use patterns in pediatric population in Bangladesh.
recognized worldwide problem of the healthcare
delivery system.4 The rational prescribing can be Therefore, the present study was undertaken to
assessed with the help of conducting prescription evaluate the pattern of drug use in different pediatric
audit on continuous basis. In recent years, drug diseases. Out-patient Department of two tertiary
utilization studies are found to be useful tool to level hospitals in Bangladesh, which may help
facilitate rational use of drugs in health care delivery clinicians to take appropriate measure for the
systems. It truly reflects the status of health care improvement of prescribing pattern and use of
system. Various indicators have been developed by essential drugs to prevent prescribing errors and thus
International Network for the Rational Use of Drugs promote rational use of drugs.
(INRUD) to allow for assessment of drug use practices
METHODS:
and suggesting remedial measures.5 Many studies
point to major misconceptions & misuse of medicines. This cross-sectional descriptive study was carried out
The design of drug use indicator studies, however in the pediatric out-patient department (OPD) of two
varies from settings to settings. While a large number tertiary care hospitals. The study population included
of drug utilization studies are available for adults all children attending at Paediatrics OPD in Sir
over the world,6,7 a few studies provide information on Salimullah Medical College & Mitford Hospital, Dhaka
drug use patterns in pediatrics. and Dhaka National Medical College & Hospital. A
total of 600 children (300 from each of the two
Pediatrics is among the most vulnerable population
selected Medical College Hospitals) were selected as
group in terms of disease acquisition. Besides,
study subjects. However, patients got admitted
pharmacodynamic and pharmacokinetics are different
during out-patient department visit were excluded
in children, which often make them more susceptible
from the study. The study population were classified
to various adverse drug reactions.8,7 Additionally, the
as low income group (monthly income<10000/
impact of maternal drug intake on neonates is also
month), middle income group (monthly income
relevant in this context. Such issues therefore call for
10000-20000/ month) and high-income group
close monitoring of drug prescribing trends in
(monthly income >20000/month). The demographic
neonates and infants.9,10 Besides, due to economic
characteristics like age and sex of the patients and
and ethical issues, children do not often participate in
medications use-related variables like dose,
clinical trials and specific knowledge about effect of
frequency, duration and route of administration of
drugs in children is often inadequate.11 Another
drugs were recorded. Pattern of drug used in the
common problem encountered in children is failure to
selected hospitals for pediatric population was
comply with therapeutic regimen due to either
evaluated with the help of World Health
inconvenient dosing schedule and/or large number of
Organization’s Core Drug Indicators to Investigate
medicines prescribed.12 Study of drug utilization
Drug Use in Health Facilities as follows (Table I):
pattern in a particular setting gives an idea about the

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 Ibrahim Card Med J 2019; 9 (1&2): 54-59  Ibrahim Cardiac Hospital & Research Institute

Table I. World Health Organization Core Drug Indicators to (83.1%) contained drugs within EDL compared to that
Investigate Drug Use in Health Facilities from DNMC (73%) (p< 0.001) (Table IV). The highest
WHO core drug use indicators prescribing drug was antibiotic, both in SSMC
Prescribing indicators (22.7%) and DNMC (23.2%) (p = 0.417) followed by
1. Average number of drugs per prescription analgesic (18% in SSMC and 17.7% in DNMC) and
2. Percentage of drugs prescribed by generic name anti-diarrhoeal (10.5% in SSMC and 10.1% in DNMC).
3. Percentage of encounters with an antibiotic prescribed The less commonly used drugs were gastric acid
4. Percentage of encounters with an injection prescribed suppressant, antispasmodic, anthelmintic, antiemetic,
5. Percentage of drugs prescribed from Essential Drug List or formulary while rarely prescribed drugs were antihistamines,
Patient care indicators* antiasthmatic and nasal drops. Pattern of drugs
6. Average consultation time prescribed in two hospitals were almost similar (p >
REVIEW ARTICLE

7. Average dispensing time 0.05) (Table V).

8. Percentage of drugs actually dispensed
Table II.Distribution of age of study subjects in the two study areas
9. Percentage of drugs adequately labeled
10. Patient’s knowledge of correct dosage Study Area
Age(years) SSMC DNMC *p-value
Facility indicators (n = 300) (n = 300)
11. Availability of copy of Essential Drug List or formulary
0–1 84(28.0) 63(21.0)
12. Availability of key drugs
1–6 124 (41.3) 128(42.7)
Some additional indices 0.181
6 – 10 82(27.3) 94(31.3)
13. Percentage of encounters with other drugs 10 – 12 10(3.3) 15(5.0)
*Number 6-10 were not included in current study *Data were analyzed using Chi-squared (χ2) Test and were presented as n(%).
Figures in the parentheses denote corresponding percentage.
The total number of drugs prescribed for 300 patients
of SSMC & MH was 946 and that prescribed for 300
Male Female
patients of DNMC was 990. The most commonly
54 52.7
prescribed drugs were noted. The number of drugs
prescribed from essential drug list of Bangladesh was 52 51.0
also studied. Data were analyzed using SPSS and the 50 49.0
Percentage

test statistics used to analyze the data were 47.3

48
descriptive statistics and Chi-squared (χ2). Level of
significance was set at 5% and p-value < 0.05 was 46
considered significant. 44
SSMC DNMC
Sex
RESULT:
The pediatric patients included from the two tertiary Figure 1: Distribution of sex by patients admitted in hospital
hospitals were almost similar in terms of age
Table III.Number of drugs prescribed per prescriptions
distribution with 1-6 years age group was the
Prescriptions Study Area
predominant (p = 0.181) (Table II). The sex *p-value
containing number SSMC DNMC
distribution was also identical between the study of drugs (n = 300) (n = 300)
groups (p = 0.369) (Fig. 1). Use of three drugs per
Two 60(20.1) 40(13.3)
encounter was commonly observed in both the
Three 140(46.6) 145(48.4)
hospitals. Around one-third of the prescriptions 0.043
contained four drugs. Prescription of five drugs was Four 94(31.3) 100(33.3)
rare in both the hospitals. Prescription with two drugs Five 6(2.0) 15(5.0)
was higher in SSMC than that in DNMC (p = 0.043) *Data were analyzed using Chi-squared (χ ) Test and were presented as n(%).
2

(Table III). Majority of the prescriptions from SSMC Figures in the parentheses denote corresponding percentage.

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Pattern of Drugs Use in Selected Paediatric Diseases in Outpatients Departments of Public and Private Teaching Hospitals in Bangladesh Afrin et. al.

Table IV. Drugs prescribed from essential drug list (EDL) of Bangladesh the average number of drugs per prescription was
significantly higher than recommended by WHO/
Study Area
*p-value INRUD. Trade names were used more often and
EDL drugs SSMC DNMC
(n = 300) (n = 300) generic prescribing was remarkably lower at private
Drugs included within EDL 786(83.1) 723(73.0) sector.
<0.001
Drugs excluded from EDL 160(16.9) 267(27.0) Essential medicines and rational use of medicines are
*Data were analyzed using Chi-squared (χ ) Test and were
2 two sides of a coin – inseparable from each other and
presented as n(%). mutually dependent. Increase in the use of essential
Figures in the parentheses denote corresponding percentage. medicines makes the medication therapy more
rational.15 In this study, 83% of the medicines could
Table V. Group of drugs used in the diseases of pediatric age group

ORIGINAL ARTICLE
be considered as essential in Sir Salimullah Medical
during the study
College & Hospital and 73% could be rated as
Most common Study Area essential in Dhaka National Medical College &
pharmacological SSMC DNMC *p-value
group (n = 300) (n = 300) Hospital. A study conducted in three tertiary hospitals
of Delhi reported 96, 94 and 74% of essential
Analgesic and antipyretic 170(18.0) 175(17.7) 0.866
medicines prescribed16 indicating that prescribing
Antibiotic 215(22.7) 230(23.2) 0.792 behavior in India for pediatric age-group is better
Expectorants & bronchodilators 78(8.2) 88(8.9) 0.613 than that in our country. One reason for this could be
Antihistamines 33(3.5) 35(3.5) 0.955 an effective and successful implementation of NEML
Antiasthmatics 22(2.3) 26(2.6) 0.671 (National Essential Medicine List) in government
Nasal drops 32(3.4) 36(3.6) 0.762 hospitals of Delhi. There is a pressing need for studies
into how medicines are being prescribed to children in
Anti-diarrheal 100(10.5) 100(10.1) 0.734
various settings and populations. Studies that have
Antiemetic 63(7.4) 55(5. 5) 0.310
investigated prescribing in populations have found
Gastric acid suppressants 80(8.4) 86(8.7) 0.856 high prescribing rates although a limited formulary of
Antispasmodic 83(8.7) 84(8.5) 0.821 medications is used.17 More medicines increase the
Anthelmintic 70(7.4) 75(7.5) 0.883 risk of drug interactions, adversely affecting the
patient compliance and hike the cost of treatment.18
*Data were analyzed using Chi-squared (χ2) Test and were
presented as n(%). Indiscriminate or prolonged prophylactic use of new
Figures in the parentheses denote corresponding percentage. antibiotics has been shown to contribute to the
emergence of multi-resistant strains in the hospital
DISCUSSION:
settings. Like antibiotics, it is difficult to justify the use
The present study was intended to assess the of analgesics on such a large scale, taking into
prescribing pattern of drugs for paediatric patients at account that prolonged and excessive use of
the tertiary level hospitals. The tertiary level hospitals analgesics may cause potential hazards.19 In
have been chosen because the prescribing patterns of Bangladesh doctors more often prescribe drugs
the out patients department of tertiary level hospitals irrationally to give quick relief of the patients without
are often copied by community practitioners and taking into consideration of the patient's disease
health workers. Irrational use of drugs is common in condition and age.16 Data obtained from the study,
developing countries with a high rate of poly- however, do not support the claims that the private
pharmacy, overuse of antibiotics, use of off-level sector hospitals are more efficient and accountable in
drugs and drugs with improper efficacy. Several rational prescribing of medications than the public
studies have documented prescribing practice in sectors do.20,21
different countries. But there is still dearth of
Inappropriate drug prescribing is a global problem.22
information on the prescribing pattern of drugs in
Misuse of drugs occurs in all countries. The irrational
paediatrics. In the present study it was observed that
prescribing behavior is especially common and costly

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 Ibrahim Card Med J 2019; 9 (1&2): 54-59  Ibrahim Cardiac Hospital & Research Institute

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